What can Australia learn from the global coronavirus fight?

Doug Hendrie

11/03/2020 4:55:07 PM

Experts say we are in a vital window of time in which we can still act to flatten the curve of the epidemic – just as other nations have.

Global map.
Australian can learn from other countries’ successes – and failures – when responding to conronavirus.

The coronavirus is now here in Australia, and may be entering a community transmission stage.
With 133 diagnosed cases as of 11 March, Australia is now at a crossroads.
Our cases are doubling every week, and further spread is likely, as Grattan Institute researchers John Daley and Matt Cowgill point out.

They argue nations with 100 cases have gone one of two ways – the Italy, China, and Iran path, with rapid spread, or the managed case load approach of Japan, Singapore and Hong Kong.
But there are also nations like South Korea, with a rapid undetected spread now showing signs of becoming contained after aggressive measures.
Nations with more than 1000 cases such as Germany, France and Spain are at risk of following Italy into an epidemic, according to analysis by Professor Mark Handley.

Public health efforts are now under way in Australia to control the spread of the virus and flatten the curve of infections. 
Flattening the curve means slowing down the rate of the epidemic so national health systems are not overwhelmed.
‘Through aggressive sanitation efforts, diligent hand-washing, canceling [sic] large gatherings, minimizing travel, teleworking, and similar measures we can flatten out the epidemic curve, keeping the number of people simultaneously infected at a low enough level to be manageable,’ Professor Carl Bergstrom wrote on Twitter.
If new infection rates are uncontained in a worst-case scenario, Australia could potentially go down the path of Italy, Iran and parts of China, which have experienced the worst effects of coronavirus, where the numbers of seriously or critically ill patients – who require mechanical ventilation – overwhelm healthcare resources and lead to far higher death rates.
On the positive side, epidemiologist Gideon Meyerowitz-Katz points out that coronavirus ‘responds extremely well to public health measures such as social distancing and quarantining’.
He cites a new paper based on Wuhan data showing that the R0 (reproduction rate) of the virus dropped from nearly four at the start of the outbreak to just 0.3 once public health measures were put in place.
That’s backed by Yascha Mounk at The Atlantic, who argues that ‘only one measure has been effective against the coronavirus: extreme social distancing.’
What can Australia learn at this key point?  
University of Queensland virologist Associate Professor Ian Mackay told newsGP that Australia has benefited from being able to see the epidemic coming, allowing us to get lab testing and pandemic plans in place. 
‘We may be able to avoid the terrible situation in Italy and Iran, which is also perhaps developing in the US,’ he said.
‘[In those countries,] it seems that spread may have taken hold before preparations were made, and so a reactive response has had to try and catch up to a fast-moving virus that has overwhelmed systems.’
‘Slowing the spread of SARS-CoV-2 is essential to maintain a functioning healthcare system to care for severe and critical cases, as well as the normal burden of disease.’
newsGP examines the different approaches and contexts for nations hit hard, and those who have been able to get ahead of the virus.
All data (except Japan) is from the John Hopkins University live coronavirus dashboard, current as of 11 March. Data is not conclusive, as the number of confirmed cases can depend on local testing regimes.
Case load managed early
1278 cases, 19 deaths, 1.5% case fatality rate (note: data is from broadcaster NHK)
When cases first appeared in Japan, there were widespread and well-founded fears about what the virus might do to a nation where more than 25% of people are aged over 65 – the demographic most at risk of dying from coronavirus.
With the coronavirus-stricken cruise ship Diamond Princess moored outside Yokohama, many feared the virus would break free.
Japan has to date been able to contain the virus, though there has been a recent uptick in cases with 59 confirmed on 10 March, the largest single-day increase since the outbreak began.
Authorities there have closed almost all schools, though public health experts like Professor Reiko Saito have questioned this approach, given coronavirus is most risky for older people.
160 cases, 0 deaths, 0% case fatality rate
Hong Kong
120 cases, three deaths, 2.5% case fatality rate
Associate Professor Mackay said both Singapore and Hong Kong have been able to contain the spread at low levels.
‘Keep in mind that no region has eradicated the virus and its presence remains a risk for infection for any susceptible person, of which there are likely to be many,’ he said.
The World Health Organization (WHO) has praised Singapore’s ‘all-government approach’ to containment, with chief Dr Tedros Adhanom Ghebreyesus stating that this approach works.
Singapore has moved rapidly to find every new case, undertake contact tracing and isolate people who are infected.
Meanwhile, Hong Kong – which is next to Guangdong Province, the second-most affected mainland China province – has moved aggressively to tackle the virus with contact tracing and quarantining.
Many businesses are closed, schools are shut and public transport connections to the mainland severed.
Many citizens are only venturing out in near-total personal protective equipment (PPE).
Rapid spread followed by aggressive containment
South Korea
7513 cases, 54 deaths, 0.7% case fatality rate
South Korea saw a very rapid undetected spread of the virus. After discovery of the major spreading cluster of cases linked to a Christian sect, authorities have moved aggressively to stem the numbers of new cases.
The nation of 51 million has rolled out widespread rapid testing, using innovative techniques like drive-thru clinics to keep healthcare workers safer.
South Korea has now effectively begun to flatten the curve, with numbers of new cases falling rapidly, as in the graph below.
Associate Professor Mackay said the South Korean example represents excellent news.
‘It suggests we may not need all of the drastic measures employed by China in order to reduce the length and size of any COVID-19 epidemic peak,’ he said.
‘Free and widespread testing for SARS-CoV-2, followed by isolation of positive cases, seems to have been an integral component for South Korea since they have turned the tide of their own epidemic.’
80,758 cases, 3136 deaths, 3.9% case fatality rate
After the coronavirus first spread from animals to humans in the Chinese city of Wuhan, local authorities were slow to respond, even trying to hush up the outbreak.  
But once it became clear that the virus was much more dangerous than the flu, the central government sprang into action.
In a New York Times interview, WHO China mission head Dr Bruce Aylward said that China’s ‘rapidly escalating outbreak’ had plateaued due to unprecedented public health efforts.
China moved half of all medical care online, Dr Aylward said, to prevent infected people spreading the virus in hospitals or clinics, and to prevent uninfected people catching it.
The 60 million people of Hubei province – by far the worst affected part of China – were effectively placed in lockdown, forced to stay in their homes and order food online.
Chinese health authorities used contact tracing to find potential cases. Once found, they ran rapid CT scans – up to 200 scans a day per machine – to catch the lung abnormalities characteristic of COVID-19 – the disease caused by the coronavirus.
People with mild infections were isolated in makeshift isolation centres set up in stadiums, while severe or critical people were sent to hospital, as were those with comorbidities or those over 65.
China also rapidly built two new hospitals and modified existing hospitals to create more isolated areas. Testing was free and the government paid for treatment gaps when a patient’s insurance ran out.
But the jury is out as to whether other nations without a centralised command structure could employ such techniques – or if all of them are necessary.
Rapid spread with difficulty containing the virus due to sustained community transmission
8042 cases, 291 deaths, 3.6% case fatality rate
The virus has spread rapidly under the radar in Iran, leading to widespread community transmission and the infection of dozens of the nation’s politicians and top officials. 
Around 8% of the nation’s politicians have been infected, and two have died.
Iran is widely believed to have understated the extent of the outbreak, with healthcare workers threatened with punishment if they speak out about rates of infection.
Opposition groups outside Iran and hospital sources inside the country believe the actual infection and death rate is higher than is being reported.
The Atlantic has listed multiple estimates suggesting that a much higher rate of infection is likely, such as estimates of how many coronavirus cases there must be to produce the number of air-travellers who have arrived in third countries with the infection. 
The average of the estimates is two million infections, around 250 times the official number.
The New York Times reports that hospitals in parts of the country are now overwhelmed, with health authorities recording different causes of death.
The country has temporarily freed more than 70,000 prisoners in a bid to reduce spread in crowded prisons, and plans to mobilise more than 300,000 soldiers to disinfect streets and combat the virus.
Many Iranians are self-quarantining whether ill or not, due to fear of the virus.
The country’s government has moved to disinfect public transport in major cities, but there are widespread shortages of tests, disinfectant and personal protective equipment.
The holy city of Qom – where the outbreak began in January – has been effectively quarantined from the rest of the country. Residents must be checked by a doctor before being able to leave the city.
United States
1009 cases, 30 deaths, 3% case fatality rate
The US has had a troubled start to tackling the coronavirus, with major issues with flawed tests holding up public health responses, as well as the news that early efforts to test for the coronavirus were rejected by authorities or lost in bureaucracy. 
The lack of a concerted national response means the US may have missed its window of containment, with a significant growth in detection of community-acquired cases.
‘We now are seeing community spread and we’re trying to help people understand how to mitigate the impact of disease spread,’ US Surgeon General Dr Jerome Adams said on CBS.
The real numbers may be higher than the official numbers, given states such as California and New York with growing numbers of cases are still struggling to scale up testing for the virus.
US pandemic expert Jeremy Konyndyk said on Twitter that the government’s response to the crisis was ‘broken’.
Rates of testing for the virus are vastly below comparable nations, at five tests per million people, while Italy’s rate is 826 per million and South Korea’s rate is 3692 tests per million.
10,149 cases, 631 deaths, 6.2% case fatality rate
Italy is now one of the worst-affected nations, with a high elderly population where the virus spread undetected for several weeks.
The entire nation has now been placed into quarantine in an effort to get on top of the virus. All public gatherings are banned, restaurants and bars have restricted hours, and cinemas, theatres, libraries and museums have been ordered to close. Schools, daycare and universities have also been closed.  
The national quarantine may be effective, as it was in China, but it will take time to have an effect.
In the interim, large numbers of serious or critical cases have swamped hospitals, leading to top Italian health official Professor Giacomo Grasselli to dub the virus ‘worse than a bomb’.
Dr Daniele Macchini, an intensivist in Lombardy, has described the impact of the virus as an ‘epidemiological disaster’ and a ‘tsunami’ that is threatening the ability of the hospital to offer care.
‘Suddenly the E.R. is collapsing … Every ventilator becomes like gold: those in operating theatres that have now suspended their non-urgent activity become intensive care places that did not exist before,’ he wrote on a Facebook post that has been translated.
The concerning account is echoed by another anonymous Lombardy intensivist, whose comments were posted by UK doctor Jason Van Schoor on Twitter.
The intensivist said that despite Lombardy’s wealth and excellent healthcare system, the virus has overwhelmed hospitals.
‘The current situation is difficult to imagine and numbers do not explain things at all. Our hospitals are overwhelmed by COVID-19, they are running 200% capacity,’ the intensivist wrote.
‘There are hundreds of [patients] with severe [respiratory] failure and many of them do not have access to anything above a reservoir mask.’
Due to the shortage of ventilators – which are essential to keeping critical patients alive through the severe pneumonia – China has now offered to send Italy 1000 ventilators, as well as large supplies of personal protective equipment and testing kits.

The RACGP has more information on coronavirus available on its website.
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Dr Sung-Lin Yang   12/03/2020 11:14:45 AM

I think its worth seeing how Taiwan addressed this issue: